Rev. Col. Bras. Cir. vol.38 número4 en a02v38n4

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Descriptive study of breast cancer cases in Goiânia between 1989

and 2003

Estudo descritivo dos casos de câncer de mama em Goiânia, entre 1989 e 2003

R

ODRIGO

D

ISCONZI

N

UNES1

; E

DESIO

M

ARTINS2

; R

UFFO

F

REITAS

-J

UNIOR

, TCBC-GO

3

; M

ARIA

P

AULA

C

URADO4

; N

ILCEANA

M

AYA

A

IRES

F

REITAS5

;

J

OSÉ

C

ARLOSDE

O

LIVEIRA2

A B S T R A C T

Objective Objective Objective Objective

Objective: To describe cases of breast cancer in women living in Goiânia from 1989-2003. MethodsMethodsMethodsMethods: We conducted aMethods retrospective, descriptive stud, which included all cases of breast cancer occurring in residents of Goiânia, identified by the Population-Based Cancer Registry of Goiânia (RCBPGO) in the period from 1989 to 2003. The variables were: age, method of diagnosis, topographic location, morphology and extent of breast cancer. We used frequencies and percentage rates, and Poisson regression to determine the annual percentage change (APC). ResultsResultsResultsResultsResults: We identified 3204 cases of breast cancer. The most frequent topographic location was the superior-lateral quadrant (53.7%). Infiltrating ductal carcinoma (IDC) was the most frequent, with 2582 cases (80.6%), followed by infiltrating lobular carcinoma (ILC), with 155 cases (4.8%). There was a significant increase of both the IDC and the ILC, with APCs of 11.0% and 15.4%, respectively. The ratio between IDC and ILC was not influenced by age (p = 0.98). As for tumor extent at diagnosis, 45.6% were located in the breast, and the APC was 16.1% (CI = 12.4 to 20.0, p <0.001). There was a trend of APC reduction of metastatic cases (-3.8, CI = -8.6 to 1.2, p = 0.12). ConclusionConclusionConclusionConclusionConclusion: The topographical location and histological type of breast cancer in the city of Goiania followed the pattern of other countries. The main morphological types were not influenced by age. There was a large increase in initial cases.

Key words Key words Key words Key words

Key words: Breast neoplasms. Women. Cross sectional studies. Incidence. Epidemiology.

Work conducted by the Goiás Mastology Research Network, Goiás, Brazil.

1. Master’s Degree, Health Sciences, Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Goiás - GO-BR; 2. Epidemiologist, Goiânia Population-based Cancer Registry, Association Against Cancer of Goiás-GO-BR; 3. Associate Professor, Department of Obstetrics and Gynecology, Federal University of Goiás -GO-BR; 4. Head, Department of Descriptive Epidemiology - International Agency for Research on Cancer (IARC); 5. Radiologist, Service of Radiation Oncology, Araujo Jorge Hospital, Association Against Cancer of Goiás-GO-BR.

INTRODUCTION

T

he incidence of breast cancer has been decreasing in

recent years in some developed countries including the

United States

1

_{. In Brazil and other developing countries, its}

incidence continues increasing

2-5

_.

In Brazil, for the year 2010, 49,240 new cases

were estimated

3

_{, representing an incidence of 49 cases for}

every hundred thousand women

2

_{, with a growth trend,}

especially for women between 40 and 59 years

5

_.

Breast cancer is the leading cause of cancer death

among Brazilian women, with mortality rates showing a

trend to stabilization

6

_{. In Goiania, the standardized mortality}

rate for world population of Segi

7

_{was 14.87/100,000 in}

1988, rising to 18.18/100 000 women in 2002

8

_.

Invasive ductal carcinoma (IDC) and invasive

lobular carcinoma (ILC) are the most common types of

breast cancer

9

_{, and its morphology tends to follow an}

international standard

10-12

_.

Although it is well established that early diagnosis

and treatment affect mortality rates and prevalence of the

neoplasia

11,13

_{, there are few data available regarding the}

descriptive epidemiology of breast cancer in Brazil.

The absence of such information makes both

the assessment of screening programs for breast cancer

and for comparison with other regions difficult. Thus, we

proposed to describe some epidemiological characteristics

of breast cancer in the female population of the city of

Goiânia in the period from 1989 to 2003, according to

variables collected by the Population-Based Cancer

Registry.

METHODS

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of women with malignancies of the breast in Goiânia, Goiás

State, Brazil.

The cases were identified in the database of the

Population-Based Cancer Registry of Goiânia (RCBPGO) and

collected in the period from 1989 to 2003. The variables

analyzed were patient age at diagnosis; diagnostic basis,

which is the form in which case information is collected

(either by cytology or histology). When these tests were

absent, data were collected by imaging or clinical data

described by the doctor.

We used the topography and morphology, as the

O3 ICD (International Classification of Diseases for

Oncology, 3rd ed.)

14

_{. The tumors with squamous cell}

carci-noma (SCC) histological type were withdrawn from the

study because the topography was originated from the skin

of the breast.

We also analyzed the extent of disease. We

considered as an in situ”lesion when the histology returned

as such, without invasion of the basement membrane;

“localized”, the invading tumor, in which histological

examination showed no axillary lymph node status and

the patient did not have detectable metastases by clinical

examination or by imaging; “regional”, when there was

reference to lymph node involvement described in histology

or, in the absent of that, there was clinically palpable

axillary lymph nodes described by the attending physician

at the staging phase; “metastasis”, when the clinical

report, imaging or histological examination showed the

presence of metastatic disease outside the breast and

ipsilateral axilla.

The eligibility criteria for inclusion of cases

followed the methodology of RCBPGO. Eligibility for

inclusion included all cancer cases diagnosed annually in

women who were residents in the municipality of Goiânia.

To avoid selection bias of patients who came from other

places to be treated in Goiania, a diagnosis of cancer should

arise in a date later than the one on which the patient fix

her residence in the city, and, for purposes of registration,

the time taken for housing the patients before the start of

treatment was six months.

We used the software SPSS ® (Statistical

Package for the Social Sciences), version 15.0, for the

making of the database. Frequencies for all variables and

analysis of central tendency were observed to determine

the mean and median age.

We used Poisson regression to calculate the

annual percentage change (Statistical Research and

Applications Branch Division of Cancer Control and

Population Sciences, National Cancer Institute, USA).

RESULTS

We collected, by RCBPGO, 3204 cases of breast

cancer in the period from 1989 to 2003. The average age

was 56 years, with a median of 53 years and standard

deviation of ± 16 years. Also in relation to age, 15.2% of

women were 40 years or less and 57% were over 50

years.

Of the total of 3204 cases diagnosed between

1989 and 2003, in 857 the topographic location could be

known. Of these, the most common location was superior

lateral (SLQ), with 53.7% (n = 461), followed by the

supe-rior medial (SMQ) in 15.8% (n = 136) and the infesupe-rior

late-ral (ILQ) 12.1% (n = 104). For other topographic locations,

the values were: inferior medial quadrant (IMQ) in 11.4%

(n = 98), overlapping lesion of the breast (OLB) in 5.01% (n

= 43), nipple-areola 1.63% (n = 14) and 0.11% in the

axillary extension (n = 1).

The most common morphology was infiltrating

ductal carcinoma, with 2582 cases (80.6%), followed by

infiltrating lobular carcinoma (4.8%). The extranodal

lymphomas and sarcomas comprised less than 1% of

ca-ses (Table 1). The analysis of trends over time showed that

both the average percentage change for invasive ductal

and invasive lobular carcinomas increased significantly

during the study period (Table 2). There was an equal

distribution of morphological types of cancer among the

age groups (Table 3).

Regarding the extent of disease, it was shown

that 45.60% of the cases were found, 19.70% had tumor

with regional extension and 10.20% had distant metastases

at diagnosis; only 4.20% (133) were in situ tumors. In this

analysis, 20.30% of cases had no information about the

extent of disease at diagnosis.

Table 1 Table 1 Table 1 Table 1

Table 1 - Absolute and relative frequencies of patients with breast cancer in Goiânia (1989-2003), according to morphology (n = 3204).

M o r p h o l o g y M o r p h o l o g y M o r p h o l o g y M o r p h o l o g y

M o r p h o l o g y NNNNN %%%%%

Other malignant neoplasms 265 8,3

Mucinous Adenocarcinoma 18 0,6

Papillary Carcinoma 16 0,5

NOS Adenocarcinoma 48 1,5

In Situ Ductal Carcinoma 45 1,4

Infiltrating ductal Carcinoma 2582 80,6

Comedocarcinoma 18 0,6

Medullary Carcinoma 20 0,6

In Situ Lobular Carcinoma 2 0,1

Infiltrating Lobular Carcinoma 155 4,8

Infiltrating Ductal Carcinoma 6 0,2

Inflammatory Carcinoma 2 0,1

Paget’s disease 11 0,3

NOS Sarcoma 10 0,3

Malignant Phyllodes Tumor 1 0,0

Malignant Lymphoma 4 0,1

Total 3204 100,0

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The rate of in situ cases was zero in 1989,

increasing to 9.80% in 2003. In contrast, we observed that

patients with advanced disease decreased from 25.38% to

6.37%. The percentage distribution of all cases, according

to tumor extension and by year of diagnosis, is shown in

figure 1. By Poisson regression, we found that the annual

percentage change was 16.1% (95% CI = 12.4 to 20.0)

for cases of localized tumors (p <0.001). For those cases

with metastases at diagnosis, there was a non-significant

reduction of the percentage average change, which was

-3.83 (95% CI = -8.6 to 1.2) (p = 0.12).

DISCUSSION

This study showed that the average age of

women diagnosed with breast cancer in Goiânia was 56

years and median of 53 years, corroborating other studies

15-17

_{. This result confirms that breast cancer is more common}

in women over 50 years of age

5,18

_{, stressing that prevention}

programs should prioritize risk age groups.

During the study period there was an increase in

the absolute number of cases of breast cancer, possibly

due to the constant changes occurring in the lifestyle of

some Goiânia women, proven by data from the Surveillance

of Risk and Protective Factors for Chronic Diseases Phone

Survey (VIGITEL), including the increased use of alcohol

and increased intake of foods with polyunsaturated fats

19

_.

Other factors that should possibly have contributed to the

increased number of cases was improving coverage of

screening mammography in the state of Goiás, which is

increasing for women over 40 years

20,21

_{, in addition to}

increasing and aging of the Goiânia population

22

_.

Confirmation of the diagnosis by histopathology,

over 90% of cases, ensures the quality of information

generated by RCBPs

23

_{, for of the 3204 patients with breast}

cancer enrolled in RCBPGO, 94.7% were confirmed by

histopathology, with a increase of 10% in the last five years.

The results confirm that the SLQ of the breast is

the anatomical location of greatest involvement for breast

cancer, followed by the SMQ, corroborating data from other

authors

24,25

_{. However, this information should be viewed}

with caution, since in 73% of cases there was no reference

to location.

Infiltrating ductal carcinoma was the most

frequently reported tumor morphology by this study,

followed by infiltrating lobular carcinoma, these findings

are similar to other works’

24,25

_{. It was also possible to}

obser-ve the significant increase of the two most common

morphological types, and the average percentage increase

of ILC was numerically greater than the one of IDC.

Although it was previously observed that age can somehow

influence the histological type

9

_{, in the present study we}

observed that the distribution of the morphological types

was not influenced by age. This finding, although

Table 2 Table 2Table 2 Table 2

Table 2 – Analysis of the evolution of the annual percentage change of the most frequent morphological types.

H i s t o l o g y H i s t o l o g yH i s t o l o g y H i s t o l o g y

H i s t o l o g y % Initial% Initial% Initial% Initial% Initial % Final% Final% Final% Final% Final APC (CI 95%)APC (CI 95%)APC (CI 95%)APC (CI 95%)APC (CI 95%) PPPPP

Invasive ductal Carcinoma 3.37 12.66 11% (9.6 - 12.4) <0.001

Invasive lobular Carcinoma 1.29 18.71 15.4% (9.2 - 22.1) <0.001

% Initial = percentage rate of the total number of cases in the year 1989; % Final = percentage rate of the total number of cases in the year 2003; APC = average percentage change; CI = confidence interval.

Table 3 Table 3Table 3 Table 3

Table 3 – Distribution of the main morphological types of breast cancer, according to age groups.

H i s t o l o g y H i s t o l o g yH i s t o l o g y H i s t o l o g y

H i s t o l o g y Age (years)Age (years)Age (years)Age (years)Age (years) T o t a lT o t a lT o t a lT o t a lT o t a l up to 39

up to 39up to 39

up to 39up to 39 40 to 5940 to 5940 to 5940 to 5940 to 59 >>>>>6 06 06 06 06 0 N

N N N

N %%%%% NNNNN %%%%% NNNNN %%%%% NNNNN %%%%%

Invasive ductal Carcinoma 395 94 1302 94 885 94 2582 94

Invasive lobular Carcinoma 24 6 77 6 54 6 155 6

x2 _{= 0,3; p = 0,98.}

Figure 1 Figure 1Figure 1

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controversial, was also observed in a previous study

26

_.

Regarding the extent of the disease, in 2002 Miller

et al.

27

_{reported that in the United States tumors localized}

only in the breast were more frequent, ranging from 54%

to 72% of cases, followed by tumors with regional extension

(axillary lymph nodes ), between 23% and 38%. For tumors

with distant metastases at diagnosis, they found rates of

3% to 9%. Unlike the statistics of developed countries, our

study showed that 45% of cases of breast cancer were

reported to be localized, 10% regional and that

approximately 20% of cases were diagnosed with distant

metastases.

The low percentage of regional tumors reported

is due to RCBPGO’s late beginning to report cases of

regionalization of breast cancer, in 1994. Probably, in

previous years, the tumors have been registered as

regio-nal metastatic tumors, justifying the difference from the

literature

28

_{. Despite this high percentage rate of patients}

with metastases at diagnosis as a whole, we observed an

important change in the Brazilian statistics from other

studies, which suggest rates of up to 70% of the diagnosis

of breast cancer in advanced stages

29,30

_{. The results}

presented are relevant, since they are based on information

from a population of approximately 674,692 female

inhabitants

22

_.

We observed an increase of carcinomas in situ

and of localized extension carcinomas, which was significant.

This change suggests that government, private and third

sector actions, in combination, may have generated benefits

for the population at risk of breast cancer, allowing early

diagnosis

21

_.

With the present study we observed that there

was a growing number of new cases of breast cancer among

the residents of Goiania in the 15 analyzed years, and finally,

the most valuable information presented, the profile

suggests that breast cancer diagnosis in the city of Goiânia

is changing, with a substantial increase in the initial

diagnosis of cases over a reduction in advanced ones.

R E S U M O

Objetivo: Objetivo: Objetivo: Objetivo:

Objetivo: Descrever os casos de câncer de mama nas mulheres residentes em Goiânia no período 1989-2003. Métodos: Métodos: Métodos: Métodos: Métodos: Estudo retrospectivo, descritivo, que incluiu todos os casos de câncer de mama ocorridos nas moradoras de Goiânia, identificados pelo Registro de Câncer de Base Populacional de Goiânia (RCBPGO), no período de 1989 a 2003. As variáveis estudadas foram: idade, método de diagnóstico, localização topográfica, morfologia e extensão do câncer de mama. Foram utilizadas frequências e taxas percentuais, além da regressão de Poisson para determinação da mudança percentual anual (MPA). Resultados: Resultados: Resultados: Resultados: Resultados: Foram identifi-cados 3204 casos de câncer de mama. A localização topográfica mais frequente foi o quadrante superior lateral (53,7%). O carcinoma ductal infiltrante (CDI) foi o mais freqüente, com 2582 casos (80,6%), seguido pelo carcinoma lobular infiltrante (CLI), com 155 casos (4,8%). Houve aumento significante tanto do CDI quanto do CLI, sendo a MPA de 11,0% e de 15,4%, respectivamente. A proporção entre CDI e CLI não foi influenciada pela idade (p=0,98). Quanto à extensão do tumor ao diagnóstico, 45,6% dos casos eram localizados na mama, sendo que a MPA foi de 16,1% (IC= 12,4 a 20,0; p<0,001). Houve tendência de redução da MPA dos casos metastáticos (-3,8; IC= -8,6 a 1,2; p=0,12). Conclusão: Conclusão: Conclusão: Conclusão: Conclusão: A localização topográfica e o tipo histológico do câncer de mama, na cidade de Goiânia, seguem o padrão de outros países. Os principais tipos morfológicos não foram influenciados pela idade. Houve grande aumento de casos iniciais.

Descritores Descritores Descritores Descritores

Descritores: Neoplasias da mama. Mulheres. Estudos transversos. Incidência. Epidemiologia.

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Received: 20/08/2010

Accepted for publication: 22/10/2010 Conflict of interest: none

Source of funding: partly funded (Research Support Foundation of the State of Goiás (FAPEG) Protocol. 200710267000252, and the Institute Avon.

How to cite this article: How to cite this article:How to cite this article: How to cite this article:How to cite this article:

Nunes RD, Martins E, Freitas-Junior R, Curado MP, Freitas NMA, de Oliveira JC. Descriptive study of breast cancer cases in goiânia between 1989 and 2003.Rev Col Bras Cir. [periódico na Internet] 2011; 38(4). Disponível em URL: http://www.scielo.br/rcbc